What constitutes a good healthcare experience for unintended pregnancy? A qualitative study among young people in California

Abstract

Little is known about young people’s experiences accessing healthcare for unintended pregnancy in the USA. To address this gap, we conducted in-depth interviews with 25 young people in California who had experienced at least one unintended pregnancy at or before 25 years of age. Participants were asked about their interactions with healthcare providers during the pregnancy, their thoughts on the determinants of their perceived quality of care, and the ways in which their healthcare experience could have been improved. Thematic analysis was used to organise information within and across interview transcripts. Two important determinants of participants’ satisfaction with their healthcare experience were identified during analysis: (1) receiving comprehensive information about their pregnancy options and what to expect from each, and (2) having an empathetic, non-judgemental provider. Regarding abortion, participants described an unmet need for accurate information and frequent stigmatising experiences with dismissive and judgemental care providers. These findings highlight the importance of providing comprehensive, non-judgemental pregnancy options counselling to all pregnant people, regardless of age and desired pregnancy outcome; and reinforce the need for providers to consider ways in which their own bias may influence the quality of care they provide.

Introduction

Unintended pregnancy – having a pregnancy that is mistimed, unwanted or unexpected – is common in the USA, particularly for young people (Finer and Zolna 2016). While the relevance of the pregnancy planning or “intendedness” paradigm has been called into question (Aiken et al. 2016; Potter et al. 2019), the frequency with which unintended pregnancy occurs and its association with at least some adverse parental and child health outcomes warrants attention (Gipson, Koenig, and Hindin 2018). In the USA, over 70 percent of pregnancies to people under 25 years of age are unintended (Guttmacher Institute 2016; Finer and Zolna 2016). This high incidence may reflect the unique complexity and uncertainty of this stage of life – the transition from child to adult. This is consistent with the recognition by many professional bodies and researchers that adolescents and young adults comprise a distinct population with unique reproductive health needs (e.g. American College of Obstetricians and Gynecologists 2017; Hornberger 2017; Daley, Sadler, and Reynolds 2013; Dobkin, Perrucci, and Dehlendorf 2013; Tilghman and Lovette 2008).

Yet, despite their frequent occurrence, unintended pregnancies experienced by young people are highly stigmatised in many settings in the USA (Moseson et al. 2019; Turan et al. 2014; Wiemann et al. 2005; Smith et al. 2016). In addition to other harms, including isolation and reduced social support (Moseson et al. 2019), the pervasive stigma attached to unintended pregnancy may act as a barrier to seeking or obtaining high-quality healthcare. For instance, young people may avoid seeking healthcare altogether for fear of being judged, may alter their communication pattern in the clinical encounter to avoid stigma (e.g. not asking certain questions), or may feel judged by healthcare providers should they seek care (Greenblatt, Cockrill, and Herold 2015). These experiences are particularly salient and concerning from the perspective of a person-centred care framework – a key domain of healthcare quality, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that people’s values guide all clinical decisions.” (National Academies of Sciences, Engineering, and and Medicine 2018). Whether or not a patient perceives their care to be of high quality is not just an issue of client satisfaction; it has also been associated, across different care settings, with important clinical outcomes, such as higher survival rates, fewer hospital admissions and fewer adverse events (Doyle, Lennox, and Bell 2013).

Toward the goal of person-centredness in the reproductive health setting, recent studies have assessed the experiences and preferences of patients with regard to contraceptive use (Dehlendorf, Diedrich, et al. 2010; Yee and Simon 2011), pregnancy options counselling (French, Steinauer, and Kimport 2017; Dobkin, Perrucci, and Dehlendorf 2013) and abortion care (Altshuler et al. 2017). This existing literature on the care needs and experiences of young people experiencing pregnancy, while limited, suggests that in the context of pregnancy, young people need care that supports their autonomy, provides unbiased information, and addresses barriers to care (e.g. Dobkin, Perrucci, and Dehlendorf 2013). However, research is scarce on the particular needs and considerations of young people experiencing unintended pregnancy, and on how the specific stigma of unintended pregnancy at a young age may influence interactions with healthcare providers.

To address this gap, we conducted a qualitative study of young people’s experiences obtaining healthcare during an unintended pregnancy at or before age 25. Specifically, we aimed to measure if and how young people accessed healthcare during an unintended pregnancy, positive and negative aspects that characterised their healthcare interactions, and the ways in which that care experience could have been improved. Additionally, as part of ongoing efforts to better understand how to describe and conceptualise unintended pregnancies, participants were asked to describe the pregnancies they had experienced in their own words, inspired by research that has highlighted wide variation in interpretation and applicability of the planned/unplanned or intended/unintended pregnancy paradigms (Aiken et al. 2016; Bachrach and Newcomer 1999; Barrett and Wellings 2002; Fischer et al. 1999). An improved understanding of young people’s preferences for unintended pregnancy care could build on healthcare professionals’ understanding of the unique needs during this age and improve the person-centredness of adolescent pregnancy care.

Methods

Study population

Study participants were recruited in the San Francisco Bay Area over an 11-month period, between February and December 2016. Recruitment occurred via Craigslist and via geo-tagged flyers at approximately 75 locations in the Bay Area (a more detailed description of study methods is published elsewhere: Moseson et al. 2019). Our target sample size was 25 individuals.

This target is consistent with sample sizes in similar qualitative studies. Individuals were eligible to participate in the study if they were 18–30 years old at the time of the interview, reported at least one unintended pregnancy when they were 25 years old or younger, spoke English or Spanish, and identified as a woman. For the purposes of screening, “unintended pregnancy” was defined as a pregnancy that was unplanned or unwanted at the time of conception. The study was approved by the Institutional Review Board of the University of California, San Francisco.

Data collection

After obtaining informed consent, participants were interviewed by the last author using a semi-structured interview guide. Interviews were conducted either in-person (at a university campus, in coffee shops, or in a park) or over the telephone (based on participant preference) and lasted approximately an hour. Informed consent was obtained in-person for the in-person interviews, and individuals were handed written information about the study to review. For telephone interviews, informed consent was obtained over the phone. Study information was read out loud and sent via text/email if the person desired to read the materials for themselves. Participants were offered a $40 gift card for their time.

The interview guide prompted participants to discuss their interactions with healthcare providers from the discovery of their pregnancy onward, including any prenatal care, abortion care, and/or labour and delivery care that was received. Participants were invited to describe interactions with any healthcare provider, across different disciplines (primary care practitioners, obstetricians/gynecologists and family planning providers alike) and different patient care settings (hospitals, clinics, etc). Participants were asked to describe aspects of their interactions with healthcare providers in each of these instances that were helpful or unhelpful and to reflect on what could have improved the care that they received. Additionally, participants were asked to choose which terms were appropriate to describe their pregnancy, with regards to intentions, plans and emotions. All interviews were conducted in English, audio-recorded and professionally transcribed.

Analysis

Interview transcripts were analysed using thematic analysis (Braun and Clarke 2006), in which both a priori and emergent themes were utilised to organise responses across interviews. The first and last authors followed an iterative code generation and application process, assessing agreement and refining code definitions at multiple points. All coding was conducted using Dedoose, an online qualitative software program (https://www.dedoose.com/). After the completion of interviews with the target sample size, the research team reviewed all interview notes and transcripts. Consistent patterns were identified across interviews, and no new themes emerged from the final interviews. It was thus the decision of the research team to not re-open recruitment, having reached a sufficient sample size (Malterud, Siersma, and Guassora 2016), as determined by the aims of the study and the consistency of themes across the conducted interviews.

Results

Recruitment

A total of 53 individuals contacted the study team to explore participation, of which, 37 were eligible, six of whom did not respond after eligibility confirmation, and an additional six did not show up for the scheduled interview. Thus, a total of 25 participants were interviewed.

Excerpts of participants’ responses are included throughout the results section. To protect participant confidentiality, participants are referred to using pseudonyms. For each participant, we state their age at the time of pregnancy, the outcome of pregnancy (and the mode of abortion if the outcome was abortion) and their self-identified race/ethnicity.

Participant characteristics and pregnancy outcomes

Study participants came from a range of racial, ethnic, and socio-economic backgrounds (Table 1), and reported a range of pregnancy outcomes (Table 1). The 25 study participants reported a total of 42 unintended pregnancies, of which 26 ended in abortion, 12 in live birth and child-raising by the participant, two ended in miscarriage, and two participants were still pregnant at the time of the interview. No participant reported a pregnancy that resulted in adoption.

Table 1.

Characteristics of 25 interview participants interviewed in the San Francisco Bay Area in 2016.

Participant characteristics
Reproductive characteristics	Mean (range)
Age	25 (19–30)
Number of pregnancies	2 (1–5)
Age at the first unintended pregnancy, years	19 (13–25)
Age at the most recent unintended pregnancy, years	21 (16–30)
Number of births	0.5 (0–3)
Number of abortions	1 (0–2)
Race/Ethnicity	n
Black/African American	7
Hispanic/Latina	7
White/Caucasian	7
Asian	4
Education	N
High School	3
Some College	10
College	9
Graduate	3

Terms used to describe the pregnancy

Participants were asked which term(s) they felt best described the unintended pregnancies they had experienced. The most commonly used terms were “unexpected” and “unintended”. The terms “unplanned” and “unwanted” were less commonly mentioned, and both were exclusively used by women who chose to terminate all prior pregnancies - but were relatively unpopular even among this group. One participant commented

“I’d say unintended and unexpected. Unwanted, yeah, I hate saying unwanted. It just sounds so f*****-up. But, yeah, unintended.”

(Ashley, 22 years old at the time of pregnancy, terminated the pregnancy by a surgical abortion, White)

Additional words, each mentioned by several participants, included “surprise” and “accident”. One participant said –

“I don’t really say it was like an unplanned pregnancy. I kind of just say, it kind of was just – it just happened. I mean, I don’t really have a word for it. I mean, to me it was just kind of like, yeah, an “uh-oh”. It was an “uh-oh”. It’s not a mistake. It was just a surprise pregnancy”

(Jessica, 16, 18, 21 and 24 years old at the time of pregnancies, continued two pregnancies, terminated one pregnancy by a surgical abortion and had one miscarriage, Hispanic)

Interactions with healthcare providers

Participants described interactions with healthcare providers in two contexts: for care related to the unintended pregnancy itself, and also for care related to preventing future unintended pregnancies. Two primary factors emerged as key determinants of the quality of participants’ interactions with healthcare providers: the type and amount of information offered by the provider, and the provider’s attitude. Participants were generally pleased with the medical care they received when their needs were met on these two dimensions, and less so otherwise.

Informational support from providers

Participants wanted clear, detailed, non-judgemental information about options for the unintended pregnancy (abortion, adoption, parenting), as well as thorough descriptions of what to expect from the abortion or birth process. One participant described a positive and informative clinical encounter upon pregnancy discovery:

“[The healthcare provider] definitely talked through – even when I said I had wanted to terminate, they walked me through all the other options that I still had available to make sure I was totally confident in my decision. (…) I appreciated that they weren’t doing it in a “You should choose a different option” way. They were just doing it in an informative [way], like just saying, “Oh, you do have these other options available” type of thing.”

(Jennifer, 22 years old at the time of pregnancy, terminated the pregnancy by a surgical abortion, Asian)

However, particularly with regard to abortion, participants who decided to have an abortion reported a substantial unmet need for information. Participants expressed wanting (but not receiving) clear, straightforward explanation about the abortion care they would receive, particularly with regard to expected symptoms and side effects. While some participants felt that their healthcare providers prepared them well, others felt that the provider’s desire to not frighten or alarm them with the details of the process caused providers to minimise the expected symptoms, leaving the patient unprepared for the experience. One participant described such an experience with regard to a medication abortion:

“I practically felt like I was dying […] I passed out in the bathroom, on the bathroom floor […] just ever[y] symptom that was literally as they described, but to an extreme. They didn’t tell me it would be that extreme. […] feeling like you’re dying on your bathroom floor was not the best feeling. That was really scary for me.”

(Sarah, 18 years old at the time of pregnancy, terminated the pregnancy by a medication abortion, Asian).

The need for accurate information about the abortion process was sometimes compounded by participants’ pre-conceived (and often misinformed) understanding of abortion based on inaccurate media portrayals. One participant described her experience of obtaining a medication abortion:

“[I] had no idea what to expect even though I knew I was taking something. I kept thinking they were going to put me in the stirrups and I would have the abortion. I had no idea. I thought I would be cut open maybe. I was flooded with all these visions, and thoughts, and things. […] If maybe there was someone who could say those bottom-line overarching statements that you fret about, like just so you know, it’s not an abortion as you’ve come to know it. It’s none of that. Abortion is an overarching term for terminating a pregnancy. You’re not having a surgery abortion […] if it was that clear it would have put me at ease now”

(Maria, 18 years old at the time of pregnancy, terminated the pregnancy by a medication abortion, Hispanic)

Several participants mentioned a specific fear that abortion would endanger their future fertility. One young woman reflected:

“The only question I really had at the time [of the abortion] was, would I be able to conceive and have children later in life? And [the doctor] assured me. […]. And I asked him again right before [the procedure] just because that was one of – I guess those are like – those are kind of one of those myths that people hear about abortion, that like, if you have one, you might have problems getting pregnant in the future. So, that was something that I was concerned about.”

(Stephanie, 16 and 19 years old at the time of pregnancies, terminated both pregnancies by surgical abortions, Hispanic)

Healthcare provider attitudes

The attitude and demeanour of the healthcare provider often determined whether the participant viewed the interaction as positive or negative. Participants expressed gratitude for empathy, non-judgemental and attention to the unique circumstances they identified in interactions with providers. At the same time, participants also spoke of feeling criticised and unsupported by providers that were rude, dismissive or outright judgemental. One participant described her positive pre-natal care experience:

“[The providers] were helpful. I felt they took care of me just like they took care of anyone else who was pregnant.”

(Emily, 22 years old at the time of pregnancy, continued the pregnancy, white).

In contrast, one participant described the layered judgement she felt from her physician for being a young, unmarried pregnant woman:

“I felt like I was treated really harshly by my OB/GYN. So, I went to one visit, and I think I had something to prove, like, “Oh, I’m in a relationship. I’m not a teen mom.” Even though if I was, I think she [should] still treat me with respect. […] I was like, “Is there any way we can schedule one of these [check-ups] after normal work hours, so [my boyfriend] can come?” […] She goes, “What? Is he invisible?” And she was accusing me of actually not having a boyfriend.”

(Taylor, 20 years old at the time of pregnancy, continued the pregnancy, white)

Participants reported feeling that bedside-manner during abortion care posed a particular challenge for health providers. Several participants recognised providers’ difficulty of navigating the line between not dramatising the experience of abortion, but at the same time not diminishing or de-personalising it. In reflecting on how the providers could have improved her abortion experience, one participant commented:

“I think if [the healthcare providers] made me feel more welcomed, or if they had tried to make conversation with me. But [their interactions with me] seemed very awkward and very, like, too professional when it wasn’t – when I didn’t want it to be professional like that. […] And I think – I wonder. I wonder, from the clinician’s point of view, if they’re just trying to be like, “[Abortion] is very common, this is routine,” so they don’t treat it as anything.”

(Michelle, 16 years old at the time of pregnancy, terminated the pregnancy by a medication abortion, Asian)

Other participants echoed this tension – appreciating providers’ attempts to normalise abortion, but commenting that in the process, this left them feeling isolated and somewhat unsupported. Another young person described her abortion experience as follows:

“Although [my abortion experience] lacked the sort of embarrassment thing, I was one of many. […] It seemed a little rushed. […] It made me feel like my problem was small in comparison, kind of like an in-and-out deal, which maybe, like, emotionally helped at the time, but sort of minimised it.”

(Hannah, 19 years old at the time of pregnancy, terminated the pregnancy by a medical abortion, white)

In short, participants recognised the complexity of factors influencing providers’ attitudes, but also lamented the lack of individual, person-centred care.

Contraceptive counselling and provision

Young people’s interactions with healthcare providers regarding post-pregnancy contraception were shaped by similar factors to other patient-provider encounters. Some contraception-related conversations were initiated by the participants, while others were initiated by their providers. Provider-initiated conversations around contraceptives were welcome to some participants, while others felt pressured or rushed by their providers to choose a contraceptive method. One participant described her experience thus:

“She was really pushing me to get birth control and just kind of like, “Well, you’ve already been pregnant twice. Do you want to make that same mistake?” And I was just like – I was by myself then, so that was the first time I went to the doctor’s by myself. And I was like – I didn’t even know what to say to her. And I was just like, “oh, my goodness. Are you serious?” I came out of there crying. […] She was so mean. She made me feel bad about getting an abortion”

(Diana, 15 and 17 years old at the time of pregnancies, terminated both pregnancies by a surgical abortion, Hispanic)

Notably, two participants reported being denied tubal ligation by their providers, on the basis of their young age at the time (despite the fact that both were over 18 years of age). One of them described this as an ongoing experience in her encounters with healthcare providers over several years:

“When I had my son, I asked them if they could tie my tubes. And they said, no. […] Yeah. I was like, “Can you please tie my tubes? I don’t want any more children.” And they said I was too young. […] I said, “Well, I’m over 18.” They said, “Well, what if you get married?” And they refused to do it. They were like, “No, you’re going to regret it.” […] And I’ve been asking the doctor – every OB/GYN doctor or primary care doctor, they would not do it. […] Even though I was over 18, they wouldn’t do it. They said, “You’re too young. You might want to have more children. You’re just saying this. You never know what’s in your future.”

(Jasmine, 20 years old at the time of pregnancy, continued the pregnancy, had subsequent unintended pregnancy at age 30, Black)

Discussion

During in-depth interviews with a diverse sample of 25 young women in the San Francisco Bay area, participants described experiences of clinical encounters with providers related to unintended pregnancy. Provision of clear, specific and direct information, combined with an empathetic and non-judgemental approach on the part of the provider, were the two most important determinants of the participants’ experience of care.

In line with our findings, previous research has affirmed the centrality of the healthcare provider’s attitude and, to a lesser extent, their provision of adequate information, in influencing the abortion care experience of people across the reproductive age spectrum in a number of high-income countries (Kjelsvik et al. 2018; Kumar et al. 2004; Makenzius et al. 2012; McIntyre, Anderson, and McDonald 2016). That information emerged as even more important in the results presented here may reflect a pronounced importance of information for young people. Making sure that people have sufficient resources – including adequate informational support – to manage their fertility is a necessary condition for reproductive justice (Sister Song Women of Color Reproductive Health Collective and the Pro-Choice Public Education Project 2007), and is an essential pillar of patient autonomy and person-centred care.

Above all, participants most desired information about abortion from their providers. Some participants had inaccurate, pre-conceived notions of abortion. This finding is congruent with existing knowledge that the media is an important source of information on abortion for adolescents and young adults in the USA (Altshuler, Gerns Storey, and Prager 2015) and that media portrayals of abortion are rarely medically accurate (Sisson and Kimport 2014). The unmet need for information about abortion calls for increased awareness on the part of providers to carefully assess each patient’s knowledge and understanding of the abortion process, and to provide them with the information they need and/or request to manage expectations and better prepare people for the care they will receive, within the context of their reproductive life-course.

Together with the provision of accurate, detailed information, participants also emphasised the importance of empathy and non-judgement in a healthcare provider. Provider empathy, one of the best-studied aspects of the patient-provider interaction, has been established as an important determinant of the patient’s healthcare experience. Provider empathy is positively correlated with increased patient satisfaction and compliance, and with decreased patient distress (Kim, Kaplowitz, and Johnston 2004; Derksen, Bensing, and Lagro-Janssen 2013). Additionally, higher provider empathy is correlated with multiple favourable clinical outcomes across different treatment settings, including better pain relief (Kelley et al. 2014), a shorter duration of the common cold (Rakel et al. 2009), better glycaemic control in diabetic patients (Hojat et al. 2011; Del Canale et al. 2012), and better outcomes of addiction treatment (Moyers and Miller 2013). Our findings affirm the importance of provider empathy for adolescent and young adult patients in the pregnancy context as well.

Beyond options for the unintended pregnancy itself, participants described interactions with healthcare providers about contraceptive options. In these settings as well, the importance of accurate information and provider empathy was clear. The context in which contraceptive advice was offered to young women had far-reaching impacts not only in how participants felt about contraceptive use but also deeper feelings of autonomy and trust in the healthcare system. We know from prior research that a patient’s race, ethnicity and socioeconomic status can influence provider recommendations for contraceptive care, regardless of the stated preferences of the individual patient (Dehlendorf, Rodriguez, et al. 2010; Dehlendorf, Ruskin, et al. 2010). Several experiences shared in these interviews suggest that patient age and reproductive history may act similarly to alter providers’ recommendations, in a way that feels dismissive and undermines the reproductive autonomy of each person. There is no “one size fits all” when it comes to contraceptive use. When asked about preferences for deciding between contraceptive options, participants in a 2010 study (Dehlendorf, Diedrich, et al. 2010) described a range of scenarios from autonomous decision-making on part of the patient, to shared decision-making, to provider-led decision making. The largest share of participants, however, desired autonomy around contraceptive choice. Providers would do well to assess patients’ decision-making preferences by direct questions, in contraceptive provision, and in other aspects of pregnancy care.

We would like to call particular attention to the experiences of two young women, who reported they were refused tubal ligation on the basis of their young age. To deny well-informed patients of their contraceptive method of choice is a breach of patient autonomy. The underlying reasoning may be related to the risk of post-sterilisation regret. Post-sterilisation regret is the most common long-term complication of sterilisation (Bartz and Greenberg 2008). Among patient characteristics, young age at the time of sterilisation is one of the strongest predictors of patient regret, with people younger than 30 years of age being at a higher risk for regret than their older counterparts (Schmidt et al. 2000; Hillis et al. 1999; Borrero et al. 2008). As pointed out by Borrero and colleagues (Borrero, Zite, and Creinin 2012), informed consent practices are often not effective enough in ensuring the patient’s understanding of the procedure. The clinician should therefore assess the patient’s perspective and circumstances, make sure that the patient is informed on the permanent nature of the procedure and on risks such as the possibility of regret, but then also assist the patient in obtaining the method of contraception of their choosing.

Study participants’ preference of the terms “unexpected” and “unintended” over the terms “unplanned” and “unwanted” sheds light on the potential differences in interpretation based on word choice. Comparison with existing literature suggests that the interpretation of these terms is associated with cultural and religious factors and may vary by whether a person has had an abortion or not (Barrett and Wellings 2002; Fischer et al. 1999). Additional studies elucidating the understanding and use of terms related to unintended pregnancy are needed to inform and improve more effective patient-provider communication, as well as for clear and specific population surveys and policy planning.

Limitations

This analysis is limited by several factors. The generalisability of findings is limited by the narrow geographic scope of the study. Almost all participants resided in the San Francisco Bay Area – a politically-liberal area, in which the availability of comprehensive reproductive health services is higher than in many other regions of the country, and therefore may not reflect the experiences of young people elsewhere. Our analysis was also limited to participants’ recollections of their healthcare experiences and did not assess other aspects of care or any potential recall bias. The study is strengthened, however, by the varied educational, racial and ethnic backgrounds of participants, and the range of clinical outcomes experienced (birth and abortion), thus offering perspectives on different facets of pregnancy care. While almost all participants were residing in the San Francisco Bay Area at the time of the interview, several participants reported on healthcare received in states other than California (Connecticut, Louisiana, Nevada and Pennsylvania). These experiences were not qualitatively different from the experiences of participants who received care in the San Francisco Bay Area. Since eligibility was limited to participants who were 30 years old or younger, and the average age at the time of the interview was 25 years of age, participants usually reported on pregnancies that occurred fairly recently in their lives, which reduces concerns about their ability to remember the details of the clinical encounters discussed.

Conclusion

This study offers insight into the healthcare experience of young people during an unintended pregnancy, across different pregnancy outcomes (birth and abortion). Findings from this study suggest that person-centred care for the young patient experiencing an unintended pregnancy should include the provision of clear, complete information about pregnancy and post-pregnancy options in an empathetic and non-judgemental fashion.

Participants had varied preferences for provider-initiated contraceptive consultation at the time of the pregnancy, and providers are advised to actively assess their patients’ preferences and to tailor the care accordingly. Providers are advised to carefully assess the use of terms such as intended or planned with regards to pregnancy, as there is variability in the perception and interpretation of these terms by pregnant patients.

The findings presented here offer a contribution to an improved understanding of young people’s preferences for unintended pregnancy care, which can ideally improve the person-centredness and quality of adolescent unintended pregnancy care.